ESH/ESC Guidelines for the management of hypertension

The 2007 European Guidelines on Hypertension have been presented at the main Scientific Meetings of the two Societies participating at the Task Force Guidelines Committee, i.e. the European Society of Hypertension and the European Society of Cardiology. The full version is published in the official scientific journals of the two societies (1-2). The new Guidelines emphasise the relevance of the assessment of total cardiovascular risk and underline the importance of therapeutic strategies aimed at effectively controlling high blood pressure and based on combination drug treatment.

Historical Background

The first Guidelines for the management of hypertension have been developed about 30 years ago by the American Joint National Committee (3). They were then followed, one year later, by the World Health Organisation / International Society of Hypertension Guidelines (4). Since then Guidelines on Hypertension have been revised and updated every 4 to 6 years with the aim at incorporating in the Document the larger amount of information on the pathophysiology, diagnosis and treatment of the hypertensive disease. In 2003, for the first time, the European Society of Hypertension and the European Society of Cardiology agreed to prepare and publish a Joint Guidelines document, which became the scientific paper most frequently quoted in the past few years (5). The 2003 Guidelines have been updated and largely rewritten in the 2007 document, whose elements of novelty are summarised in Table 1.

2007 ESH/ESC Hypertension Guidelines: the Novelties

The 2007 Guidelines confirm the definition and classification of essential hypertension based on blood pressure values already mentioned in the 2003 Guidelines, underlining the importance of different types of blood pressures as well as of the assessment of end organ damage and total cardiovascular risk. In the diagnostic evaluation of the patients, 2007 Guidelines confirm the list of the examinations already mentioned in the 2003 version. The only exception is the disappearance of protein C levels assessment, which appears, with only few specific exceptions, as a marker of inflammation that is too generic to be employed as a prognostic tool.
Another major element of novelty comes from the statement that a large proportion of benefits comes from the blood pressure reduction “per se” and that protection of treated hypertensive patients largely comes from the blood pressure reduction “per se” and only in part from the type of drug treatment.

Cardiovascular risk stratification and assessment of organ damage

One of the peculiar features of the ESH/ESC 2007 Guidelines on hypertension is the relevance assigned to the assessment of subclinical organ damage, given the evidence that this evaluation is of crucial importance for assessing total cardiovascular risk. Some of the organ damage measures are of routine evaluation (EKG, echocardiography, microalbuminuria, creatinine) while other, more expensive measures, are recommended for a more-in-depth assessment of cardiovascular risk reserved to particular clinical conditions. However, new Guidelines stress the importance of microalbuminuria as a simple, feasible, cheep and precise test for evaluating organ damage, taking into account its ability to predict in the long-term period both renal outcome and cardiovascular events.

Two “new” measures for the assessment of end-organ damage have been recommended, i.e. the ankle-brachial ratio and the pulse wave velocity. Both these measures, which reflect alterations in arterial stiffness, have been shown to represent sensitive and accurate markers of the atherosclerosis disease. Their use, however, has to be implemented in the next few years. Another key aspect of 2007 Guidelines refers to the recommendation that organ damage should be assessed not only before treatment but also during treatment in order to closely monitor throughout the years the effects of antihypertensive drug treatment on structural and functional alterations of the cardiovascular system. This indication is of particular relevance, given the evidence that an improvement in organ damage closely mirrors a reduction in cardiovascular events, thereby indicating a greater cardiovascular protection.

Therapeutic approach

Evidence accumulated over the years has conclusively shown the importance of blood pressure reduction “per se” for protecting the hypertensive patient. Blood pressure thresholds for initiating treatment are set at values : 140/90 mmHg in the majority of hypertensive patients, but below this threshold in high risk individuals. This is a difference from the recommendations made in previous Guidelines (5), emphasising the importance of the so-called “flexible threshold” for treatment, which is based not only on the elevation of blood pressure values but also on the assessment of total cardiovascular risk profile. This latter parameter thus becomes crucial for treatment strategy.

The 2007 Guidelines make three other key points for treatment. First, they affirm that non-pharmacological measures for treatment of hypertension, based on lifestyle changes, should be implemented mainly in the early phases of the therapeutic intervention preceding the pharmacological approach. Second, 2007 Guidelines emphasise the importance of blood pressure reduction “per se” for lowering cardiovascular morbidity and mortality associated with hypertension.

Finally, the 2007 Guidelines touch another issue of major clinical relevance, namely the need to have an optimal or near-optimal blood pressure control during treatment. This goal should be pursued by making use of combination drug treatment, which should be used not only when monotherapy is ineffective but also as first-line treatment option. The rationale for this statement is based on the evidence that achievement of a full blood pressure control in a shorter time period means greater cardiovascular protection (6). Among the combination treatments available, the 2007 ESH/ESC Guidelines recommend the following ones (Figure 2):

• Thiazide diuretics plus ACE-inhibitors
• Thiazide diuretics plus angiotensin II blockers
• Calcium antagonists plus ACE-inhibitors
• Calcium antagonists plus angiotensin II blockers
• Calcium antagonists plus thiazide diuretics
• Beta-blockers plus calcium antagonists

A final “hot therapeutic” issue deserves to be briefly mentioned, namely the position of beta-blockers as antihypertensive drugs. Although the British Guidelines (7) seem not to consider beta-blockers as first line treatment, the 2007 ESH/ESC Guidelines still retain these compounds as first line antihypertensive drugs particularly in those patients in which the blood pressure elevation is associated with clinical conditions such as angina, previous myocardial infarction and heart failure.

Conclusions

The 2007 ESH/ESC Guidelines represent an updated and detailed document on the clinical relevance of high blood pressure, cardiovascular risk profile and antihypertensive treatment. They also represent a useful guide for daily clinical practice. Successful implementation of the 2007 ESH/ESC Guidelines in current clinical practice will hopefully allow to promote an improvement in the disease management and in patients’ outcome. 

Elements of novelty in the 2007 ESH/ESC Guidelines 

Metabolic Syndrome
Relevance of subclinical damage
Importance of Renal dysfunction (GFR, creatinine clearance)
Microalbuminuria
Left ventricular concentric remodeling associated with increased cardiovascular risk
Multidistrictual organ damage assessment
Arterial distensibility and ankle/brachial ratio
Relevance of end-organ damage assessment before and during treatment
Heart rate as possible prognostic marker in hypertension